Mission Trip Application Church Member*North CampusSouth CampusNorthgate CampusOtherChurch* Full Passport Name* First Middle Last Nick Name First Last If different than passport nameMission Destination*MexicoCosta RicaHondurasThailandZimbabweWalesMiddle EastBurkina FasoOtherDates You Will Be Traveling* Passport Number If you don’t have an updated passport, please submit to Missions a copy of your passport when you receive it.Expiration Date on Passport If applying for one, please write "applying for".DOB (Date of birth)* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Email* Enter Email Confirm Email Beneficiary Name* First Last For Insurance PurposesT-Shirt Size*X-SmallSmallMediumLargeX-LargeXX-LargeShirts are Unisex SizeContact Person While You Are Away* First Last Relationship* Cell Phone*Email* Deposit*Pay Deposit OnlinePay By CheckAlready Paid$100 deposit for Haiti & Honduras is due February 1. $100 deposit for all other trips is due March 1.Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name
